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What does the Coronavirus pandemic mean for Cosmetic Surgery?

Coronavirus has caused devastating effects on our health and our society and it almost feels vulgar to even discuss what effect it is having on the cosmetic treatment industry. But you can’t help but notice the plaintive posts on social media such as “when can I get my next filler treatment?” or “OMG my Botox has worn off!” The lockdown has led to the closure of non-essential high street establishments including hair and beauty salons and clinics offering non-invasive treatments such as Botox, fillers and fat freezing. The NHS has temporarily taken over private hospitals throughout the country in case of the NHS becoming overwhelmed by Coronavirus, thankfully it hasn’t, which means that there is no cosmetic surgery taking place. We don’t know yet when clinics will be able to reopen or when normal(ish) services will resume in private hospitals. But we can expect cosmetic surgery operations to resume more slowly whilst the backlog of more urgent procedures is got under control. For those patients that are awaiting their cosmetic treatment who may have this open-ended postponement is no trivial matter. Multiple studies have demonstrated that many patients suffer genuine psychological anguish because of their physical appearance and gain a great deal in terms of quality of life from their surgery. For example, patients with very prominent ears or marked breast asymmetry.

So what can you do if you are somebody who is cursing the lockdown for its delay on your treatment? Well if it’s a non-invasive treatment such as dermal fillers or Botox you’ve got a bit of time. Fillers last at least 6 month and Botox starts to wear off after 3 months. Thread Lifts (dissolving threads passed under the skin that lift drooping skin, especially in the face) last 9 to 18 months. Whatever you do, resist the temptation to purchase products online for self-injection (yes, really). This may seem far fetched but fillers in particular, as non-medicinal products, are very easy to come by over the Internet. Self-injection is best avoided as inadvertently injecting a blood vessel can have disastrous consequences. Whilst you are waiting for your clinic to reopen you can focus on keeping your skin healthy by having a healthy diet, applying daily moisturiser and avoiding getting sunburnt. Lockdown may be a good opportunity for some to stop smoking which is known to accelerate facial ageing. If you are awaiting cosmetic surgery, it is even more important to focus on your health. The fitter you are the less risk you will have of experiencing a complication such as delayed wound healing and you will recover quicker. Many cosmetic operations such as tummy tuck, breast lift or arm lift involve removing excess skin, so if you can reduce your weight the surgeon will be able to remove more skin meaning a better aesthetic outcome.

It is inevitable that the coronavirus pandemic will lead to changes, some permanent, in the healthcare and cosmetic surgery industries. In the short term clinics and hospitals will have to take extra precautions to prevent patients catching coronavirus and for some patient the added risk of coronavirus may tip the balance against having surgery. There will be less capacity in private hospitals to undertake cosmetic operations because they will be busy dealing with their own and the NHS backlogs. The pressures on the NHS from the Coronavirus, which are going to persist for months if not years, mean that explicit judgements will have to be made on which treatments and operations are more worthwhile than others. There is no doubt that treatment for serious diseases such as cancer will be top of the list but it may mean that the waiting times for conditions that aren’t life threatening go up. In that environment it’s easy to imagine that society may view the cosmetic surgery as frivolous or unnecessary in which case fewer people may be inclined to have it. On the other hand the inhibitions on foreign travel will lead to fewer people going abroad for cosmetic surgery. Given the dangers of flying before and after surgery (blood clots) and the difficulties managing postoperative complications this is probably a good thing.

Coronavirus will be beaten, there are already several promising vaccines being trialled. The human desire to look and feel as attractive as we can will persist. Ultimately this awful pandemic is unlikely to kill off the cosmetic surgery industry. So relax, that annoying wrinkle is living on borrowed time!

Richard Baker

Hand and Wrist Joint Replacements

There are many joints in the hand and wrist, and they are prone to developing arthritis just as other joints in the body. Arthritis means pain, swelling and reduced motion due to wear and tear within the joint, or more specifically loss of the soft cartilage surface of the joints. This occurs in all of us as we age, but in a minority of people it leads to pain. An effective way of relieving pain in joints is to remove the joint entirely and fuse the bones together. However, this means the joint does not move at all.

An alternative that preserves motion is to replace the joint with a mechanical device or prosthesis. There are some advantages to replacing joints in the hand and wrist. Firstly, the hand and wrist are not weight-bearing joints in contrast to the hip and knee, so they do not have to be as strong. Secondly, the hand is more resistant to infection than other parts of the body because of its excellent blood supply. The disadvantage of the hand as a site for joint replacement is that there are no muscles crossing the individual joints in the hand; for example, there is no muscle in the fingers. This means that the joints are inherently less stable than, for example, the hip and knee.

Body Contouring and Weight Loss

Massive weight loss is defined as when a person loses 50% or more of their excess body weight. For example, if a person weighs 100 kg but their ideal body weight would be 60 kg on the basis of their height, then their excess body weight is 40 kg and if they lost 20 kg or more, this would be massive weight loss.

Some people achieve this through diet and exercise and others through surgery, in particular gastric bypass, which is a very effective procedure and even cures type II diabetes. Inevitably, after losing a great deal of weight, there is excess skin which does not contract back down to its original size. This is because the skin is stretched beyond its elastic capacity; for example, an elastic band that is held outstretched for a long period will eventually lose its elastic recoil.

Unfortunately, it does not matter how much time elapses since the weight loss; the skin never regains the elasticity of normal skin. The skin also becomes much thinner. The excess skin tends to hang in folds and this causes problems with clothes, taking exercise, personal hygiene and affects people’s self-esteem and relationships. Therefore, removing this excess skin, so-called ‘body contouring’, is a very worthy endeavour.

Buried Penis Syndrome

Obesity causes many problems including arthritis, high blood pressure, heart disease, diabetes and difficulty exercising, but in men it causes another problem that is rarely talked about – buried penis syndrome. This occurs in men who put on weight because the fat underneath the skin pushes the skin outwards to eventually bury the penis, which is attached to the underlying bone of the pelvis and therefore cannot expand outwards with the skin. The problem can reach such a point that men can no longer see their own penis. It makes passing urine difficult with dribbling and this can lead to another condition called balanitis. It is thickening and tightening of the foreskin and the end of the penis (or glans) as well as narrowing of the water pipe. It predisposes to cancer of the penis but also, because of the increased pressure required to pass water, leads to problems with the kidneys.

Arthritis of the thumb

Arthritis at the base of the thumb is very common particularly, in women over the age of 40 years old. It’s probably caused by weakening of the ligaments over the years through exposure to estrogen which is the female hormone. Weakening of the ligament means the thumb partially dislocates from its joint on the hand leading to wear and tear of the cartilage which is essentially what arthritis is. It leads to new bone formation, causing spikes of bone which can dig into the surrounding flesh and causing inflammation of the tissues around the joint. This leads to pain but also to deformity of the joint and reduced range of motion, strength and function. In many patients it’s painful for a few years and then burns it’s self out. In other patients, it’s persistently painful and these patients require treatment. The main treatment is avoiding activities that cause pain but also wearing splints at times of exacerbation of pain, taking pain killers, both tablets but also creams and gels which can be applied to the skin, steroid injections where the steroid is injected directly into the joint under a local anaesthetic, sometimes it’s necessary to use ultrasound on an x-ray machine to ensure the needles are in the right place, very often this can be administered in clinic. Often the joint is more painful after a steroid injection for a day or two and it can take several days for the steroid to kick in and can last up to six months. Steroid injections can be repeated over time and tend to last for shorter and shorter periods. We’re not quite sure why steroid injections work but steroids dampen down inflammation and inflamed tissue is painful.

Breast Uplift and Implants

This week I’ve seen several patients who are seeking breast uplift and implants. Otherwise known as augmentation mastopexy. It strikes me after seeing several different types of patients requesting this surgery, that there are two main groups of patients who request this but actually need slightly different operations. The first type of patient is a woman who’s had children and has breast fed and has lost volume, such that the breasts have then become deflated and droopy. These patients require a small implant to restore lost volume particularly in the upper part of the chest as well as a lift to tighten up the skin and reduce the droopiness. As a small implant is being used and no breast tissue is being removed, this can be safely performed in one procedure.

Facial Rejuvenation Surgery

This week I have been doing a bit of reading and thinking about aesthetic surgery of the face. By ‘face’ I mean the skin and underlying fat and muscles of the face and neck, but I am not really talking about the eyelids, the nose or the mouth as such because these areas have very particular anatomical features and require a discussion of their own. The tissues of the face consist of skin, fat, muscle and the underlying bone, and all four of these structures give the face its overall shape. Furthermore, all four of these tissues change with age and contribute to the changing facial appearance.

Wrist Injuries

This week I have seen a number of wrist injuries and I have been thinking about their natural history of and my approach to them. There are two general mechanisms of wrist injury which divide the patients into two groups.

The first group tends to be young men involved in a high energy injury such as coming off a motorcycle, coming off a bicycle at speed, falling off a skateboard, throwing a punch of falling from a height such as a ladder at work, for example.

The second group tends to apply to women and children in particular and is a lower energy injury, typically tripping over and landing on the outstretched hands.

Tummy tuck surgery – improving results

This week I’ve been thinking about how to improve results in abdominoplasty, or ‘tummy tuck’, surgery. The commonest causes of dissatisfaction after abdominoplasty are residual excess skin, particularly when bending forwards, excess skin in the flanks and fluid collection under the skin (seroma). It is important to warn patients before surgery that though the skin can be very tight on the day of surgery, it naturally relaxes over the following weeks to months so that inevitably there is some degree of returning laxity over the following year. However, it is nowhere near to the same extent as before the surgery. In addition, the patient doesn’t get new younger skin, they simply have the excess removed. Unfortunately, aging, weight gain and pregnancy all have the effect of thinning the skin such that it loses the firmness and elasticity of youth. Liposuction helps in removal of loose skin because the suction of the fat layer allows you to stretch the skin further. Obviously, this is more effective the thicker the layer of fat.

HIFU and Miradry

I attended the CCR expo in London which is the aesthetic surgery conference and exhibition.

I was particularly interested to hear about the new technologies such as HIFU, which is high frequency ultrasound treatments for tightening the skin and reducing the fat content which helps improve the contour of the face, neck and body; I’m thinking about introducing this to my patients.